Get Xerox Provider First-Level Appeal Request

Any party to the initial claim determination that is dissatisfied with the decision may request a redetermination.

If you have a Medicare health plan, start the appeal process through your plan. Follow the directions in the plan's initial denial notice and plan materials. You, your representative, or your doctor must ask for an appeal from your plan within 60 days from the date of the coverage determination.

An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies: A request for a health care service, supply, item, or drug you think Medicare should cover.

Yes! You can appoint a representative to appeal a denial on your behalf. To appoint a representative, complete the Appointment of Representative form and mail it to either your MAC (if you have Original Medicare) or your Medicare Advantage Plan.

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

Adjudicator – The entity responsible for making the decision at any level of the Medicare claim decision making process, from initial determination to the final level of appeal, on a specific claim.

The medical provider is responsible for submitting a claim to Medicare for the medical service or procedure. If Medicare denies payment of the claim, it must be in writing and state the reason for the denial.

File a complaint (grievance) File a claim. Check the status of a claim. File an appeal. Appeals if you have a Medicare health plan. Get help filing an appeal. Your right to a fast appeal. Authorization to Disclose Personal Health Information (PDF)